Reimbursement FAQs

What is the difference between a Thyrogen® (thyrotropin alfa for injection) wholesale order and a retail order?

An order is referred to as wholesale when a physician or outpatient facility purchases Thyrogen from a distributor, pays the distributor and bills the patient’s health plan for reimbursement. An order is referred to as retail when the physician or outpatient facility places an order for Thyrogen from a distributor and the distributor bills the patients’ health plan. Whether Thyrogen is purchased as a wholesale or retail order is determined by the patient’s plan.

Is the co-pay for Thyrogen the same as the co-pay for other prescription drugs on a patient’s plan?

The co-pay is determined by the terms of the patient’s policy. Sometimes an injectable drug will have a co-pay or co-insurance that is different from the co-pay or co-insurance for oral medications. A patient’s co-pay or co-insurance can be confirmed when the patient’s insurance benefits are verified by ThyrogenONE.

Is Thyrogen covered by Medicare?

Thyrogen is covered by Medicare Part B when it is administered and billed as incident to physician services. Medicare will not prior authorize, so a patient’s Medicare coverage policy should be understood before Thyrogen use is initiated. For information on Medicare coverage for Thyrogen, please contact ThyrogenONE or your local Medicare Part B carrier.

What is the Thyrogen reimbursement rate for Medicare?

For 2009 the Medicare allowable reimbursement rate for Thyrogen in the physician office setting is calculated as 106% of the Average Sales Price (ASP) and the Medicare allowable reimbursement rate for Thyrogen in the hospital outpatient setting is calculated as 104% of the Average Sales Price (ASP). Medicare will reimburse 80% of the allowable amount. The remaining 20% is the responsibility of the patient or the patient’s supplemental or secondary plan. The allowable amount is updated quarterly the Centers for Medicare and Medicaid Services (CMS) based on data reported by drug manufacturers.

Is Thyrogen covered by Medicaid?

Medicaid eligibility and benefit plans vary from state-to-state, so the local state’s program’s coverage policy should be understood before treatment is initiated. Usually, use of Thyrogen will need to be considered medically necessary in order to be covered under the Medicaid program. Depending on the state, use of Thyrogen may require prior approval by the state Medicaid program. For information on Medicaid coverage for Thyrogen in your state, contact ThyrogenONE or your local Medicaid office.

What is the Thyrogen reimbursement rate for Medicaid?

Medicaid reimbursement rates for Thyrogen will vary from state to state. For information on Medicaid coverage for Thyrogen^® in your state, contact ThyrogenONE or your local Medicaid office.

Does Medicaid require prior authorization for Thyrogen?

Some state Medicaid offices may require prior authorization. Requirements for prior authorization can be confirmed when the patient’s insurance benefits are verified by ThyrogenONE.

Is Thyrogen available through the Medicare Part B Competitive Acquisition Program (CAP) in 2009?

On September 10, 2008, the Centers for Medicare & Medicaid Services (CMS) announced the postponement of the 2009 CAP program. Physicians enrolled in the CAP program for 2008 will be able to obtain Medicare Part B CAP covered drugs, including Thyrogen through the approved CAP vendor through December 31, 2008. Beginning January 1, 2009, physicians must obtain and bill for Part B CAP covered drugs, including Thyrogen through the ASP process, and physicians will also be responsible for collecting applicable deductible and co-insurance from Medicare beneficiaries.

In early 2008, CMS accepted bids for vendor contracts for the 2009-2011 CAP program. While CMS received several qualified bids, contractual issues with the successful bidders resulted in CMS postponing the 2009 Program. As a result, CAP physician election for participation in the CAP in 2009 was not held, and CAP drugs will not be available from an approved Cap vendor for dates of service after December 31, 2008.

Additional information regarding CAP and the 2009 postponement of CAP can be accessed via the CMS website at: www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp

Is there a program available for patients that are uninsured or those that have been denied payor coverage for Thyrogen?

The Thyrogen Patient Support Program was established by Genzyme to help qualified patients receive Thyrogen. Please direct requests for application forms, and more specific eligibility information regarding the program to ThyrogenONE at 1-88-THYROGEN.